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Darwin Award Nominee Phillipsburg, NJ An unidentified 29 year old man choked to death on a sequined pastie he orally removed from an exotic dancer. The dancer referred to only as Ginger said, She didnt know he was going to eat it.

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Resuscitation CPR – BLS designed to maintain circulation of oxygenated blood to the heart and brain until definitive medical treatment can restore normal or sufficient heart and ventilatory function – Rapid EMS response with early ACLS required for best chances of survival

58
Case Scenario An 14 year old female presents for routine restorative dentistry. She has never had a cavity diagnosed until today. She is in your office and will need two simple Class I restorations.

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Case Scenario Prior to the injections you note she is sighing frequently. During the injections, she yells that it hurts and starts crying. She becomes panicky and inconsolable. Two minutes later she starts complaining of midsternal chest pain.

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Case Scenario What is your diagnosis?

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Case Scenario Five minutes after the injections, she becomes unconscious.

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Case Scenario A 25 year old male construction worker presents for removal of his third molars. He has 4 erupted thirds which you feel you can remove without difficulty or sedation. He has come from a job site. The outside temperature today was 103 F. He passed up his usual beers after work with his buddies.

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Case Scenario During administration of local anesthesia, he becomes jittery, pale and diaphoretic. He appears anxious and disoriented.

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Case Scenario What is your differential diagnosis? – Be specific! What would you do first? What is your treatment?

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Case Scenario Vital signs – BP - 80/40 – P – 80 regular – R – 14

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Case Scenario After your treatment, he recovers sufficiently to allow you to do the extractions. The case goes well and after the procedure, the assistant sits him up and he again becomes faint and dizzy. A half hour later, you need to go home. You put him in a wheelchair and your assistant takes him to his car.

78
Case Scenario His girlfriend who met him at your office will drive him home. When he stands up to get into the car, he passes out.

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Case Scenario What is your differential diagnosis? – Be specific! How does treatment for this differ from your previous treatment? How can you differentiate clinically between these two types?

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Syncope

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Syncope and death are the same – except that in one you wake up. Anonymous

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Syncope Incidence – Presyncope -Universal – Syncope-50% Syncope accounts for ~ 3% of all ER visits and may account for up to 6% of hospital admissions

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Syncope Definitive diagnosis of syncope is made in only about 50% of case. ER physicians can make a definitive diagnosis in only ~ 25% of cases 25% of all patients referred to cardiologist for cardiac work-up have syncope and not cardiac disease

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Pathophysiology of Syncope Lack of oxygen and blood to the brain – Nonspecific with multiple causes Lack of glucose to the brain Seizure activity

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Seizures and Syncope Difficulty is determining whether the seizure caused the faint or the faint caused the seizure – Generalized clonic jerks result from cerebral anoxia – Cant rely on tongue-biting and urination

105
Case Scenario An IV is started and she is given Versed and Fentanyl initially. She receives 1 g of Kefsol IV as antibiotic prophylaxis and 2 minutes later complains of itchy skin, develops a diffuse patchy rash, watery eyes and a runny nose. She feels nauseated and complains of stomach cramps.

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Generalized Anaphylaxis Usually rapid onset (5 to 30 minutes, occasionally delayed for hours) Respiratory and cardiovascular problems predominate and occur early in the reaction Death can occur in minutes

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Local Anesthetics Allergy History – Must try to differentiate between true allergy, overdose, intravascular injection, vasoconstrictor reaction or idiosyncratic reaction Requires good dialogue history with patient – If questionable history, refer to allergist

125
Penicillin 2.5 million people allergic Allergic reaction reported in 5-10% of patients receiving penicillin Fatal reaction in 1 per 100,000 Most frequent cause of generalized anaphylaxis in dental practice

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Angina Pectoris May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X) Uncommon in males less than 40 Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia

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Myocardial Infarction Pain more intense and longer in duration than angina pectoris Pain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectoris Not relieved by SL nitroglycerin or cessation of activity

161
Angina Pectoris May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X) Uncommon in males less than 40 Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia

176
Myocardial Infarction Pain more intense and longer in duration than angina pectoris Pain described as retrosternal, crushing, pressure, constriction, vice-like, burning Pain may occur in same distribution as angina pectoris Not relieved by SL nitroglycerin or cessation of activity

186
Case Scenario She receives 6 carpules of 2% Xylocaine with 1:100,000 epinephrine. Five minutes later, she tells the hygienist that she feels really great. She stutters as she says it and she now has twitching of her facial and extremity muscles. She begins to perspiring and c/o the room being hot.

187
Case Scenario You are summoned back to the room. When you enter, she begins to seize in the chair.

188
Case Scenario What do you suspect is happening? How would you treat it? What is the pathophysiology for this problem? How can this occur and what are the differences?

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Overdose

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Clinical signs and symptoms from high blood levels of a drug in various target organs and tissues Most common adverse drug reaction

200
Just what drugs do you need? Do I need a crash cart? How extensive does your crash cart need to be? What if I dont have the training to use the equipment?

201
Crash Cart

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How much do you need? What is your training? – Match your training to the amount of drugs and equipment you require Do not overbuy via an emergency kit. – Small tackle box may be all that is necessary vs, major crash cart Must have certain necessary equipment to administer the drugs in your emergency kit or temporaily treat emergencies (needles, fluids, tubing, tourniquets, etc.)

203
Oxygen All medical emergencies require oxygen initially! – What specific conditions require oxygen? – What is the one exception?

204
Aspirin

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81, 162 or 325 mg crush and swallow Who should be on it? Who gets it? What does it do? How does it supposedly work?

206
Epinephrine

207
What concentrations does it come in? Name 3 dental office emergencies where you would consider using it? What is the normal dosage? How often can it be repeated? – Why would you repeat it? What adverse effects could occur?

210
What forms does it come in? When is it given? How often is it given? How do you know it is effective/active? How does it work? How is it stored? What are the adverse side effects?

211
Atropine Sulfate

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Indications? How does it work? How much do you give? What adverse side effects can occur? How often can you repeat it?

213
Benadryl

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Name 3 dental emergencies in which this is used? How is it administered? What dosage is usually given? How does it work? What are the side effects?

215
Ventolin Inhaler

216
Used to treat what conditions? How much and how often can it be administered? How should it be administered? Side effects?

217
Insta-Glucose

218
Used to treat what condition? When should this not be used? How is it administered?

219
Dextrose - 50

220
Used to treat what condition? How is it given? Can it produce any problems if administered?

221
Succinylcholine

222
What is it and what is it used to treat what conditions? How is it administered and how much is given? How long does it take to be effective and how long does it last? How is it metabolized? What must you be able to do if you administer this medication? Are there any risks to administration of succinylcholine?

223
Narcan

224
For what condition is this used? How is it administered? What special precautions must be utilized? What are the risks of giving this medication? If the patient doesnt respond after repeated dosing, what is suggested?

225
Romazicon

226
For what condition is this used? How is it administered? What is the maximum dosage? What risks are associated with giving this medication?

227
Valium

228
For what condition is this used? How much and how is it given? What is the biggest concern with giving this drug?